For 24/7 referrals please contact us at - Phone: (225) 663-2881 Fax: (225) 355-1555

EMPLOYMENT APPLICATIONPrint

Application Information
Full Name: Date:
Last First M.I.
Address:
Street Address Apartment/Unit #
City State ZIP Code
Phone: E-mail Address:
Date Available: Social Security No.: Desired Salary:$
Position Applied for:
Are you a citizen of the United States?  Yes No If no, are you authorized to work in the U.S.?  Yes No
Have you ever worked for this company?  Yes No If yes, when?
Have you ever been convicted of a felony?  Yes No If yes, explain:
List any friends or relatives working for us
Education
High School: Address:
From: To: Did you graduate?  Yes No Degree:
College: Address:
From: To: Did you graduate?  Yes No Degree:
Other: Address:
From: To: Did you graduate?  Yes No Degree:
References
Please list three professional references.
Full Name: Relationship:
Company: Phone:
Address:
 
Full Name: Relationship:
Company: Phone:
Address:
 
Full Name: Relationship:
Company: Phone:
Address:
Previous Employment
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
 
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No
 
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
 
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No
 
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
 
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No
 
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
 
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No
 
Military Service
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

If I am employed by this organization, I consent to any future drug/alcohol test which may be required or requested by the organization, including random tests. If employed by the organization, I consent to an inspection of my person, vehicle, locker, desk and personal property while I am on duty or on company property.

Under the provisions of the Fair Credit Reporting Act U.S.C., Sec. 1681, et seq. notice is hereby given that a consumer report or investigative consumer report may be made which include information pertaining to your employment history, educational background, credit worthiness, character, general reputation, driving record, criminal record, personal characteristics, and mode of living, which will be used for employment purposes. An investigation into your worker’s compensation or industrial accident claims background may be conducted under the guidelines of the American with Disabilities Act.

You are further advised under said act that any person who procures or causes to be prepared an investigative consumer report on any consumer shall, upon written request by the consumer within a reasonable period of time after the receipt by him of the disclosure required by subsection 1681 (d), shall make a complete and accurate disclosure of the nature and scope of investigation requested. This disclosure shall be made in writing, mailed or otherwise delivered, to the consumer five days requested after the date on which the request for such disclosure was received from the consumer or such report was first requested, which ever is the latter.

You are further advised that if you are denied employment, either wholly or partly, because of information contained in a consumer report as that term is defined in the Fair Credit Reporting Act, that a disclosure will be made to you of the name and address of the consumer reporting agency making such report

I, the undersigned, have read the above and foregoing notice and understanding the same. I hereby authorize the property or its designated representative to investigate and verify facts stated by me on the attached application

If employed, I will be required to compete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

Applicant Signature: Date:
Supervisor Signature: Date:
Witness: Date:

This organization is an equal employment opportunity employer. We adhere to policy of making employment decisions without regard to race, color, age, sex, religion, national origin, handicap, marital status or veteran status. We assure you that your opportunity for employment with this organization depends solely upon your qualifications.

Interviewers Comments
Interviewer Date Comments
Reference and Prior Employment Check
Individual Contacted Name of Firm Results of Check
For Personnel Office Use
Hired: For What Department:
Salary: Year/Month/Hr Start Date:
   

You can print this form and mail us or fax it to 225-355-1555.

Apollo Behavioral Health Hospital provides admission services 24 hours a day 7 days a week. Contact us at (225) 663-2881 or 1-855-435-4322.You can fax the referral packet to 225-355-1555

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